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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T �. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP gt WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .2, t% 7�" City/Town D / _ <br /> Owner's Name AD Phone <br /> Address °'S C f8 .S F City Lai' <br /> Contractor's Name />-Q CI i'` '' License# /&-Q 3 Business Phone' 3 — S 3 <br /> Contractor's Address O 0k" G' O Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 0 —RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ ^C4, <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> t Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL 1:1CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout' I <br /> ❑ DISPOSAL ❑ OTHERS` Other Information <br /> ❑ GEOPHYSICAL / Surface Seal Installed By: <br /> )(PUMP INSTALLATION: Contractor 3G/X4 aj" , <br /> Type of Pump V2/,her,_$ 6 e— H.P. <br /> PUMP REPLACEMENT:. ❑ State Work'Done <br /> PUMP REPAIR: _❑ State Work Done ; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure y� 1 <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San'Joaquin Local Health_District. <br /> Home owner or licensed agent's signature certifies the following:';I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: ;;ro n <br /> Date: . <br /> t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date—�'��� <br /> Additional Comments: <br /> Phase 11 Grout Inspection as II Final Inspection \ t <br /> Inspection By <br /> Date M _ <br /> 1 4 Inspection By f��� . Date L4 <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July t R Received By July 31 <br /> r <br /> 'BILLING REMITTANCE $ -REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE, REMITTED AMOUNT <br /> FEE S� t ¢ 50� <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> t <br /> Received byate Receipt No. 'Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />